Cavitary Coccidioidomycosis With Fungus Ball Formation: Case 1

A 20-year-old woman was transferred to Fitzsimons Army Medical Center for evaluation of hematemesis, possible hemoptysis, and a cavity of the right lung. Over a period of 7 years, she had experienced nausea and abdominal pain with intermittent hematemesis; chest pain and hemoptysis were also described. These symptoms, although intermittent, occurred as frequendy as every 1 to 2 weeks. Previously, an upper gastrointestinal barium examination and esophageal duodenoscopy (EGD) had been performed and results were normal (within a year). She also underwent a fiberoptic bronchoscopy that was reported as normal 6 years before hospital admission. Five months prior to transfer, a 2.2 X 2.5-cm right midlung cavity was detected. On repeated chest radiograph during the month of transfer, the cavity measured 2.7 X 3.0 cm (Fig 1). Laboratory examination at the transferring hospital revealed no acid-fast bacilli in sputum; serologic tests were negative for С neoformans (latex antigen), С immitis (immunodiffusion), and Histoplasma capsulatum (complement fixation). An anergy skin test battery was negative for purified protein derivative, mumps, and histoplasmin; however, it was positive for Candida.
In an emergency department in North Dakota, she experienced three episodes of hematemesis/hemoptysis with positive gastric lavage for blood 11 days prior to hospital admission. She denied fever, chills, weight loss, sweats, melena, or bright red blood per rectum. She also denied tuberculosis exposure. She had lived in Arizona until the age of 15 years. Repeated EGD showed cholangiectatic areas along the greater curvature of the stomach. buy antibiotics online

The patient had a 2-year history of migraine headaches. She denied alcohol and tobacco use, had no known allergies, used no medications, and had undergone a tonsillectomy. Laboratory examination showed a leukocyte count of5,700 mm with 13 percent eosinophils; hematocrit was 41 percent. Findings from the remainder of the laboratory analysis were not helpful.
Multiple angiodysplastic lesions in the stomach (20) were visualized and cauterized per EGD during her hospitalization. A coccidioidin skin test (1:100) was negative. Repeated chest radiograph and chest computed tomographic scan (Fig 2) were compatible with a fungus ball; a bronchoscopy with biopsy was performed. Iodine wet mount and subsequent histopathologic study showed mixed hyphal forms and spherules (Fig 3). A pure culture of С immitis was obtained. No further difficulties were encountered and the patient was discharged from the hospital on a regimen of cimetidine and a combination of aluminum hydroxide, magnesium hydroxide, and simethicone (Mylanta). Antifungal therapy was withheld and she continues to do well to date, with no change in the cavity on chest radiograph 18 months later.

Figure-1

Figure 1. Left, Chest radiograph demonstrating right lower lung cavity. Right, Enlargement of Fig 1 left showing cavity.

Figure-2

Figure 2. Chest computed tomographic scan showing “crescent” sign of fungus ball due to coccidioidomycosis.

Figure-3

Figure 3. Biopsy specimen showing predominantly hyphal forms (arthroconidia) (Gomori-methanamine silver stain, original magnification X400).

This entry was posted in Cavitary Coccidioidomycosis and tagged amphotericin, bronchoscopy, cavitary coccidioidomycosis, hemoptysis, hyphae spherules, lobectomy, skin test.